<p> Feline House Soiling Questionnaire Patient Name: Date: Client Name: Thank you for allowing us to be a part of your pet’s healthcare. Our hospital is a full- service veterinary hospital with a focus on preventative care in addition to general medicine and surgery. To help us get to know your pet’s health, facilitate your experience, avoid appointment delays or rescheduling, p lease complete this form within 48 hours by email (or fax) of your first appointment (including newly adopted patients with minimal histories to pets with extensive medical histories). Please fill out one form for each pet to the contact information below.</p><p>Has your pet been to a veterinarian before?  Yes  No (skip to question 2) If yes, please list the most recent 3 veterinary clinics (at least name, city/state – ideally phone number or email address if feasible). If the pet was previously listed under another name or individual on the medical chart please note that also. E.g. Two Rivers Veterinary Hospital, West Fargo, ND 701.356.5588 [email protected] 1. 2. 3. Cats can display house-soiling (urinating and/or defecating outside of the litterbox) for many conditions. To help streamline your visit with appropriate testing/treatment it is important for us to have the answers to the following questions prior to your appointment:</p><p>Duration of symptoms (days/months/years): </p><p>Number of cats in the house: </p><p>Confidence (if > 1 cat) that patient today is the cat urinating outside the box: </p><p>Number of litterboxes: </p><p>Location of litterbox(es) (e.g. furnace room, bathroom, etc): </p><p>Size of litterbox (e.g. standard, jumbo, longer than cat, size of cat, etc): </p><p>Are the litterboxes hooded: </p><p>Are liners used in the litterbox:</p><p>Are any of the litterbox(es) automated: </p><p>How often is litter scooped: </p><p>How often is litter changed: </p><p>Locations (specifically rooms and locations within rooms) that Kringer is urinating: </p><p>Type of material/substrate(s) that Kringer is urinating on? (e.g. carpets vs clothes versus hardwood, etc):</p><p>Are the surfaces more vertical or horizontal: </p><p>Any changes in litter type, food:</p><p>Any potential changes in house that could be a stressor (e.g. new pet, visitors, vacation, etc): </p><p>Brand of diet (and duration fed): </p><p>Canned or dry diet (or both): </p><p>How are the spots being cleaned that are soiled (product, process): </p><p>What is the response to your pet when found soiling or soiled regions:</p><p>Email: [email protected] Phone: 701.356.5588 Fax: 701.356.5589 Have any therapies already been tried (and response): </p><p>Bloodwork evaluated within last 60days (diabetes, kidney disease, etc): </p><p>Xrays performed (bladder stones) and/or ultrasound: </p><p>Urine cultured (to confirm infection/antibiotic selection or resistances): </p><p>Any behavioral management therapies tried (thundershirt, Feliway sprays/collars/diffusers/etc): </p><p>2. Do you consider your pet overall healthy at home? If unsure, please list the top concern(s) you may like us to further address during the visit. No concerns at this time (skip to question 3) Yes (please specify below) 1st concern:</p><p>2nd:</p><p>3rd:</p><p>4th:</p><p>5th:</p><p>What medications is your pet currently taking? *Please bring in with you to your appointment</p><p>Vitamins/Minerals Flea/Tick Monthly parasite Other prescriptions – (e.g. omega fatty acid, SynoviG4s (e.g. Parastar Plus, Frontline preventative include frequency/dose (e.g. topical shampoos, glucosamine/chondroitin sulfate, Plus, K9 Advantix) (e.g. Sentinel, Heartgard Rimadyl, etc) etc) Plus, Revolution)</p><p>Any other questions/comments that would benefit our team: </p><p>Sincerely, Tracie Hoggarth, DVM and Teri-Lee James, DVM MPH</p>